I was over at Linkedin reading a discussion about “the drama of manipulation; is it necessary?” I have a fair understanding of the research surrounding the use of manipulation for painful conditions, both the evidence for treatment of ‘musculoskeletal’ pain and mechanism based treatment. Here is my reply...

For a basic review mechanisms please see:

Bialosky, J. E., Bishop, M. D., Price, D. D., Robinson, M. E., & George, S. Z. (2009). The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Manual Therapy, 14(5), 531–538.
Wellens, F. (2010). The traditional mechanistic paradigm in the teaching and practice of manual therapy: Time for a reality check., 1–12.

Pickar, J. (2002). Neurophysiological effects of spinal manipulation. The Spine Journal.
So is the drama necessary. It’s hard to argue that it isn’t.

First, why are you doing it? It is difficult to defend biomechanical themes.

Lederman, E. (2011). The fall of the postural-structural-biomechanical model in manual and physical therapies: exemplified by lower back pain. J Bodyw Mov Ther, 15(2), 131–138.

There is no reliable, valid way to justify where you perform your manipulation.

Palpation doesn’t make sense…

Haneline, M., Cooperstein, R., Young, M., & Birkeland, K. (2009). An annotated bibliography of spinal motion palpation reliability studies. The Journal of the Canadian Chiropractic Association, 53(1), 40–58.

Cornwall, J., & DipPhty, B. (2004). Anatomy in practice: Lumbar zygapophysial joint Palpation. NZ Journal of Physiotherapy.

Pushing on bones doesn’t make sense…

Landel et al. Intertester reliability and validity of motion assessments during lumbar spine accessory motion testing. Physical Therapy, 88(1), 2008.

Beneck et al. The relationship between lumbar segmental motion and pain response produced by a posterior-to-anterior force in persons with non-specific low back pain. JOSPT, 35(4), 2005

Maher et al. An investigation of the reliability and validity of posterioranterior spinal stiffness judgements made using a reference-based protocol. Physical Therapy, 78(8), 1998.

Maher and Adams. Reliability of pain and stiffness assessments in clinical lumbar spine examination. Physical Therapy, 74(9), 1994.

Unless you like confirmation bias…

Fritz, J. M., Whitman, J. M., & Childs, J. D. (2005). Lumbar spine segmental mobility assessment: an examination of validity for determining intervention strategies in patients with low back pain. YAPMR, 86(9), 1745–1752.

We don’t change tissue with manual therapy…

Bialosky, Joel E., et al. "The relationship of the audible pop to hypoalgesia associated with high-velocity, low-amplitude thrust manipulation: a secondary analysis of an experimental study in pain-free participants." Journal of manipulative and physiological therapeutics 33.2 (2010): 117-124.

Flynn, T., Fritz, J., & Wainner, R. (2003). The audible pop is not necessary for successful spinal high-velocity thrust manipulation in individuals with low back pain. Archives of physical medicine and rehabilitation

Ianuzzi, A., & Khalsa, P. S. (2005). Comparison of human lumbar facet joint capsule strains during simulated high-velocity, low-amplitude spinal manipulation versus physiological motions. The Spine Journal, 5(3), 277–290.

Tullberg: Spine, Volume 23(10).May 15, 1998.1124-1128

Threlkeld, A. (1992). The effects of manual therapy on connective tissue. Physical therapy.

We don’t even know what is moving…

Ross, J. K., Bereznick, D. E., & McGill, S. M. (2004). Determining cavitation location during lumbar and thoracic spinal manipulation: is spinal manipulation accurate and specific? Spine, 29(13), 1452–1457.

Bolton, A., & Moran, R. (2007). An investigation into the side of joint cavitation associated with cervical spine manipulation. International Journal of Osteopathic Medicine.

The physical therapy profession has pushed hard since 2002 to use certain criteria suggesting two to five factors improve outcomes when using manipulation…

Fritz, J. M., Childs, J. D., & Flynn, T. W. (2005). Pragmatic application of a clinical prediction rule in primary care to identify patients with low back pain with a good prognosis following a brief spinal manipulation intervention. BMC family practice, 6(1), 26-29

Flynn, T., Fritz, J., Whitman, J., Wainner, R., Magel, J., Rendeiro, D., et al. (2002). A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine, 27(24), 2835–2843.

Childs, J. D., Fritz, J. M., Flynn, T. W., Irrgang, J. J., Johnson, K. K., Majkowski, G. R., & Delitto, A. (2004). A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Annals of internal medicine, 141(12), 920–928.

More recently, it appears these criteria are less about a specific technique…

Cleland, J., Fritz, J., Kulig, K., & Davenport, T. (2009). Comparison of the effectiveness of three manual physical therapy techniques in a subgroup of patients with low back pain who satisfy a clinical prediction rule. Spine, 2009.

…and give us a prognosis…

Cook, C. E., Learman, K. E., O'Halloran, B. J., Showalter, C. R., Kabbaz, V. J., Goode, A. P., & Wright, A. A. (2013). Which Prognostic Factors for Low Back Pain Are Generic Predictors of Outcome Across a Range of Recovery Domains? Physical therapy, 93(1), 32–40.

This intervention is not region specific…

de Oliveira, R. F., Liebano, R. E., Costa, L. D. C. M., Rissato, L. L., & Costa, L. O. P. (2013). Immediate Effects of Region-Specific and Non-Region-Specific Spinal Manipulative Therapy in Patients With Chronic Low Back Pain: A Randomized Controlled Trial. Physical therapy.

Aquino, R., Caires, P., & Furtado, F. (2009). Applying joint mobilization at different cervical vertebral levels does not influence immediate pain reduction in patients with chronic neck pain.

Schomacher, J. (2009). The effect of an analgesic mobilization technique when applied at symptomatic or asymptomatic levels of the cervical spine in subjects with neck pain: a randomized controlled trial. The Journal of manual & manipulative therapy, 17(2), 101–108.

Walser, R. F., Meserve, B. B., & Boucher, T. R. (2009). The effectiveness of thoracic spine manipulation for the management of musculoskeletal conditions: a systematic review and meta-analysis of randomized clinical trials. The Journal of manual & manipulative therapy, 17(4), 237–246.

González-Iglesias, J., Fernández-de-Las-Peñas, C., Cleland, J. A., & Gutiérrez-Vega, M. D. R. (2009). Thoracic spine manipulation for the management of patients with neck pain: a randomized clinical trial. Journal of Orthopaedic and Sports Physical Therapy, 39(1), 20–27.

Cleland, J. A., Childs, M. J. D., McRae, M., Palmer, J. A., & Stowell, T. (2005). Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial. Manual Therapy, 10(2), 127–135.

Cleland, J. A., Childs, J. D., Fritz, J. M., Whitman, J. M., & Eberhart, S. L. (2007). Development of a clinical prediction rule for guiding treatment of a subgroup of patients with neck pain: use of thoracic spine manipulation, exercise, and patient education. Physical therapy, 87(1), 9–23.

Cleland, J. A., Glynn, P., Whitman, J. M., Eberhart, S. L., MacDonald, C., & Childs, J. D. (2007). Short-term effects of thrust versus nonthrust mobilization/manipulation directed at the thoracic spine in patients with neck pain: a randomized clinical trial. Physical therapy, 87(4), 431–440.

…and speed doesn’t matter:

Cook, C., Learman, K., Showalter, C., Kabbaz, V., & O'Halloran, B. (2012). Early use of thrust manipulation versus non-thrust manipulation: A randomized clinical trial. Manual Therapy.

Leininger, B., Bronfort, G., Evans, R., & Reiter, T. (2011). Spinal manipulation or mobilization for radiculopathy: a systematic review. Physical Medicine and Rehabilitation Clinics of North America, 22(1), 105–125.

Boyles, Robert E., et al. "The addition of cervical thrust manipulations to a manual physical therapy approach in patients treated for mechanical neck pain: a secondary analysis." The Journal of orthopaedic and sports physical therapy 40.3 (2010)

Gross, Anita, et al. "Manipulation or mobilisation for neck pain: a Cochrane Review." Manual therapy 15.4 (2010): 315-333.

Jull, G., Trott, P., Potter, H., Zito, G., Niere, K., Shirley, D., et al. (2002). A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine, 27(17), 1835–43.

Walker, M. J., Boyles, R. E., Young, B. A., Strunce, J. B., Garber, M. B., Whitman, J. M., et al. (2008). The effectiveness of manual physical therapy and exercise for mechanical neck pain: a randomized clinical trial. Spine, 33(22), 2371–2378.

Hurwitz, E. L., Morgenstern, H., Harber, P., Kominski, G. F., Yu, F., & Adams, A. H. (2002). A randomized trial of chiropractic manipulation and mobilization for patients with neck pain: clinical outcomes from the UCLA neck-pain study. American journal of public health, 92(10), 1634–1641.

Leaver, A. M., Maher, C. G., Herbert, R. D., Latimer, J., McAuley, J. H., Jull, G., & Refshauge, K. M. (2010). A Randomized Controlled Trial Comparing Manipulation With Mobilization for Recent Onset Neck Pain. Archives of Physical Medicine and Rehabilitation, 91(9), 1313–1318.

While I'm thinking about it, a n=14 makes it difficult to defend speed or cervical manipulation. It is also important to note the samples disability, fear avoidance and pain levels were low in comparison to individuals seeking physical therapy services.

Puentedura, E. J., Landers, M. R., Cleland, J. A., Mintken, P. E., Huijbregts, P. E. T. E. R., & Fernández-de-Las-Peñas, C. (2011). Thoracic spine thrust manipulation versus cervical spine thrust manipulation in patients with acute neck pain: a randomized clinical trial. J Orthop Sports Phys Ther, 41(4), 208-20.

If you are still set on defending speed with the ‘subgroup’ mentality, then you may want to discuss this study:

Puentedura, E. J., Cleland, J. A., Landers, M. R., Mintken, P. E., Louw, A. D. R. I. A. A. N., & Fernandez-de-Las-Penas, C. É. S. A. R. (2012). Development of a clinical prediction rule to identify patients with neck pain likely to benefit from thrust joint manipulation to the cervical spine. J Orthop Sports Phys Ther, 42(7), 577-592.

It’s hard to overlook to the low fear avoidance, disability and pain levels. With that said, expectation shows up within the regression analysis and shows the highest sensitivity.

I feel I should mention there is some evidence that high speed vs. low speed improves outcomes at 48-96 hours:

Dunning, J. R., Cleland, J. A., Waldrop, M. A., Arnot, C. F., Young, I. A., Turner, M., & Sigurdsson, G. (2012). Upper cervical and upper thoracic thrust manipulation versus nonthrust mobilization in patients with mechanical neck pain: a multicenter randomized clinical trial. J Orthop Sports Phys Ther, 42(1), 5-18.

Cleland, J. A., Glynn, P., Whitman, J. M., Eberhart, S. L., MacDonald, C., & Childs, J. D. (2007). Short-term effects of thrust versus nonthrust mobilization/manipulation directed at the thoracic spine in patients with neck pain: a randomized clinical trial. Physical therapy, 87(4), 431–440.

Am I saying this approach should be thrown out or the baby with the bath water? No, but it could be argued it is not necessary. To suggest not providing someone with manipulation is doing him or her a disservice or non-evidence based is absurd (no citation required; opinion). Ignoring the abundance of research pointing toward non-connective tissue mechanisms, we should acknowledge and accept the non-musculoskeletal approach of the ‘technique’ and understand the ‘drama’ that does explain its effectiveness.

From an efficacy standpoint, it is difficult to defend. For a review of these concepts please see…

Fritz, J. M., & Cleland, J. (2003). Effectiveness versus efficacy: more than a debate over language. Journal of Orthopaedic and Sports Physical Therapy, 33(4), 163–165.

Now that we understand efficacy vs. effectiveness, I think this is a good time to ask ourself:
If I had a painful ‘musculoskeletal’ (all pain is neurogenic, besides the point) condition, would I want a treatment that has effectiveness or demonstrates efficacy?

Before I forget, would you like some kinesiotape with that Mr. Smith?

Saavedra-Hernández, M., Castro-Sánchez, A. M., Arroyo-Morales, M., Cleland, J. A., Lara-Palomo, I. C., & Fernández-de-Las-Peñas, C. (2012). Short-term effects of kinesio taping versus cervical thrust manipulation in patients with mechanical neck pain: a randomized clinical trial. Journal of Orthopaedic and Sports Physical Therapy, 42(8), 724–730.

If you understand this concept you accept this treatment impacts us from a psycho-social-neuro-immuno-endocrine-insert-random system standpoint. What does this mean? The technique has much less to do with the outcome as suggested.
You and your patient’s expectation plays a role:

Bishop, M. D., et al. "Patient Expectations of Benefit from Interventions for Neck Pain and Resulting Influence on Outcomes." The Journal of orthopaedic and sports physical therapy (2013).

Reme, S., Hagen, E., & Eriksen, H. (2009). Expectations, perceptions, and physiotherapy predict prolonged sick leave in subacute low back pain. BMC musculoskeletal disorders, 10(1), 139.

Myers, S. S., Phillips, R. S., Davis, R. B., Cherkin, D. C., Legedza, A., Kaptchuk, T. J., et al. (2008). Patient expectations as predictors of outcome in patients with acute low back pain. Journal of general internal medicine, 23(2), 148–153.

Turner, Judith A., et al. Worker recovery expectations and fear-avoidance predict work disability in a population-based workers’ compensation back pain sample. Spine 31.6 (2006): 682-689.

Bialosky, Joel E., Mark D. Bishop, and Joshua A. Cleland. "Individual expectation: an overlooked, but pertinent, factor in the treatment of individuals experiencing musculoskeletal pain." Physical therapy 90.9 (2010): 1345-1355.

Bialosky, Joel E., et al. "The influence of expectation on spinal manipulation induced hypoalgesia: an experimental study in normal subjects." BMC musculoskeletal disorders (2008).


Getting along with your patient or improved therapeutic alliance plays a role:

Ferreira, P. H., Ferreira, M. L., Maher, C. G., Refshauge, K. M., Latimer, J., & Adams, R. D. (2013). The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Physical therapy, 93(4), 470–478.

Hall, A. M., Ferreira, P. H., Maher, C. G., Latimer, J., & Ferreira, M. L. (2010). The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: a systematic review. Physical therapy, 90(8), 1099–1110.

Reducing fear avoidance plays a role:

Crombez, G., Vlaeyen, J. W., Heuts, P. H., & Lysens, R. (1999). Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability. PAIN, 80(1-2), 329–339.

Ciccone, D. S., & Just, N. (2001). Pain expectancy and work disability in patients with acute and chronic pain: a test of the fear avoidance hypothesis. The journal of pain : official journal of the American Pain Society, 2(3), 181–194.

Fritz, J. M., & George, S. Z. (2002). Identifying psychosocial variables in patients with acute work-related low back pain: the importance of fear-avoidance beliefs. Physical therapy, 82(10), 973–983.

George, S. Z., Fritz, J. M., Bialosky, J. E., & Donald, D. A. (2003). The effect of a fear-avoidance-based physical therapy intervention for patients with acute low back pain: results of a randomized clinical trial. Spine, 28(23), 2551–2560.

Pain catastrophizing plays a role:

Severeijns, Rudy, et al. "Pain catastrophizing predicts pain intensity, disability, and psychological distress independent of the level of physical impairment." The Clinical journal of pain 17.2 (2001): 165-172.

I could go on with fMRI, placebo studies, context, pain science, etc but I’m spent. Reviewing fifty-eight articles for one post is enough for me.

So do I think the drama is necessary? I do. If the intention is to maximize the outcome, using some form in-depth examination (magical hands on testing and identification of a ‘problem’) mixed with a repertoire of hands on maneuvers with audible pops and clicks, patient re-assurance you have fixed the ‘problem,’ therapist confidence, good interaction, empathy, the list goes on. Do we need this intervention to provide these same outcomes? I would argue the answer is no. It can be done with education, movement and exercise. Education is no different than using a manual therapy approach. It takes practice and proficiency. It needs to be adapted to the patient’s beliefs and values. It has plenty of evidence to support it (systematic reviews and randomized trials to case reports) and I don’t feel like adding another ten citations.

So in conclusion, if you feel the need to push others to crack joints, do me a favor and perform some meta-cognition on why you continue this passive intervention. Do we need more passive interventions? Should people in pain leave the clinic with no further understanding of their pain experience? Should we continue to foster the idea of being fixed?

-sorry for the citation formats. My papers program is a little goofy with citation for certain articles.